The Epidemiology of Modern War
War, deliberate violence between organized groups of human beings, has been a feature of human society for thousands of years. However the effect of war on non-combatants has changed dramatically in the past century.
About 85% of the people killed in the First World War were uniformed combatants. Military strategists have since devised ways to protect their own forces from the deadly effects of ever more powerful modern weapons. Those who fire the most destructive weapons are now well protected from their effects, including the psychological effects of seeing what they do to other human beings. Thus Hellfire missiles are fired from Predator drones over Iraq and Afghanistan by people sitting at computer terminals at Nellis Air Force base a few miles from the casinos of Las Vegas.
Likewise, enemy combatants, the nominal targets, make use of evolving defensive technologies and strategies, from high-tech armor to asymmetric warfare, to protect themselves from all this destructive power. This leaves tragically unlucky and defenseless civilians as the principal victims of modern warfare. The inevitable consequence is that about 90% of the casualties in modern wars are civilians, not combatants.
The public perception of war in developed countries has not quite caught up with this reality. When Americans complain about censorship of the news from Iraq, they are generally asking to see more flag-draped coffins, not more reports of children dismembered by American aerial weaponry. The reality that children dismembered by “precision” weapons are a far more common feature of this war than flag-draped coffins is still too disconcerting for most Americans to accept, and neither politicians nor media executives are prepared to face the consequences of breaking the spell.
However, professionals in the fields of public health and epidemiology have recognized that the cumulative effects of violence, displacement, disease and hunger that afflict civilian populations in wartime constitute grave public health crises. Epidemiologists have made great strides in their ability to accurately assess the human consequences of war in order to facilitate appropriate responses.
In 1994, as refugees poured out of Rwanda into the area around Goma in Zaire, the U.N. High Commission for Refugees found itself responsible for hundreds of thousands of traumatized, dislocated people who were now facing new threats to their lives. Cholera, meningitis and dysentery were breaking out and spreading through this population already devastated by a genocidal civil war.
The CDC in Atlanta and Doctors Without Borders dispatched a joint team to quickly train health workers in identifying, recording and analyzing the spread of this multiple epidemic, to provide the UNHCR with the accurate data it needed to confront the problem and save as many lives as possible. One member of this team was a post-doctoral fellow in epidemiology from the CDC named Les Roberts, and his experience in Zaire shaped the direction his work has taken since then.
After leaving the CDC, Roberts became the Director of Health Policy for the International Rescue Committee, a New York-based NGO that provides relief to victims of war in many parts of the world. In this capacity, he has conducted epidemiological studies in about twenty war-zones around the world. In 2000, this brought him back to eastern Congo. Troops from eight different countries allied with politically well-connected Western mining interests had turned the region into a living hell for the civilian population. Humanitarian intervention was an extremely dangerous proposition, but it was feared that hundreds of thousands of people were dying in a “complex emergency” that was difficult to accurately assess.
Roberts’ team conducted a “cluster sample survey”, which balanced the very real danger to their own safety with the need to survey statistically meaningful samples from randomly selected clusters throughout the region. He concluded that, while 200,000 civilians had been killed in the war, another 1.5 million excess deaths had occurred as a result of diarrhea, measles, malnutrition, malaria, anemia and meningitis, all preventable diseases under other circumstances.
His report concluded, “In Eastern DRC, war means disease…Violence and infectious disease deaths are inseparably linked.” The epidemiologists found evidence of previously undetected outbreaks of measles, cholera, polio and meningitis.
U.N. Secretary General Kofi Annan presented the I.R.C.’s findings to the Security Council, resulting in a resolution that called for the withdrawal of all foreign armies from the Congo. Nigeria and South Africa volunteered troops for a U.N. peacekeeping force. The U.N. doubled its international aid target for the Congo, and the U.S. State Department cited the I.R.C. study in announcing a grant of $10 million in emergency aid.
Then, in September 2004, Roberts joined Dr. Gilbert Burnham of Johns Hopkins School of Public Health and an international team of epidemiologists to conduct a similar “cluster sample survey” of excess civilian deaths caused by the war in Iraq.
The team’s findings contradicted central elements of the narrative of the war that politicians and journalists were presenting to the world. After excluding the results from Anbar province as a possible statistical anomaly, they estimated that at least 100,000 Iraqi civilians had died in the previous eighteen months as a direct result of the invasion and occupation of their country. They also found that violence had become the leading cause of death among civilians in Iraq during that period, accounting for at least half the excess deaths. However, their most significant finding was that the majority of violent deaths were caused by coalition forces using “helicopter gunships, rockets or other forms of aerial weaponry”, and that almost half of the civilian dead in these attacks were children, with a median age of eight.
When the team’s findings were published in the Lancet, the official journal of the British Medical Association, they caused quite a stir, and it seemed that an important step had been taken toward a more realistic accounting of the human cost of this war. The authors made it clear that their results were approximate; they explained the limitations of their methodology and emphasized that further research was urgently needed to give a more precise picture.
More than a year later, we do not have a more precise picture. Instead of releasing their own records of civilian casualties or facilitating further research, the American and British governments launched a concerted campaign to discredit and marginalize the Lancet study. Today the continuing aerial assault on Iraq that it exposed is still a dark secret to most Americans, and the media still present the same general picture of the war, focusing on secondary sources of violence.
Les Roberts has been puzzled and disturbed by this response to his work, which stands in sharp contrast to the way the same governments responded to his study in the Democratic Republic of Congo. As he says, “Tony Blair and Colin Powell quoted those results time and time again without any question as to the precision or validity”.
Roberts had conducted a follow-up study in the Congo that raised the fatality estimate to 3 million, and Tony Blair cited that figure in his address to the 2001 Labor Party Conference. However, in December 2004, Blair dismissed the epidemiological team’s work in Iraq, claiming that, “Figures from the Iraqi Ministry of Health, which are a survey from the hospitals there, are in our view the most accurate survey there is”.
This statement by Blair is particularly interesting because the Iraqi Health Ministry reports whose accuracy he praised have in fact confirmed the Johns Hopkins team’s conclusion that aerial attacks by coalition forces are the leading cause of violent civilian deaths in Iraq. Nancy Youssef covered one such report in the Miami Herald on September 25th 2004 under the headline “U.S. Attacks, Not Insurgents, Blamed for Most Iraqi Deaths”.
The Health Ministry had been reporting civilian casualty figures based on reports from hospitals, as Mr. Blair said, but it was not until June 2004 that it began to differentiate between casualties inflicted by coalition and resistance forces. In the three months from June 10th to September 10th it counted 1,295 civilians killed by U.S. forces and their allies and 516 killed in “terrorist operations”. Health Ministry officials told Ms. Youssef that the “statistics captured only part of the death toll”, and emphasized that aerial bombardment was largely responsible for the higher numbers of deaths attributed to coalition forces.
BBC World Affairs Editor John Simpson reported on another Health Ministry survey that covered the six months from July 1st 2004 to January 1st 2005. This report cited 2,041 civilians killed by U.S. and allied forces versus 1,233 by “insurgents”. Then something strange but sadly predictable happened. The Iraqi Health Minister’s office contacted the BBC and claimed in a contradictory and confusing statement that its figures had been misinterpreted; the BBC issued a retraction; and numbers of civilians killed by coalition forces have been notably absent from subsequent Health Ministry reports.
So, the British and American governments and the U.N. responded positively to Roberts’ work in the Congo and elsewhere, and Iraqi Health Ministry reports have supported his findings in Iraq despite the subsequent denial. Official and media criticism of his work has focused on the size of his sample, 988 homes in 33 clusters distributed throughout the country, but other epidemiologists reject the notion that this is controversial.
Michael O’Toole, the director of the Center for International Health in Australia, says: “That’s a classical sample size. I just don’t see any evidence of significant exaggeration… If anything, the deaths may have been higher because what they are unable to do is survey families where everyone has died.”
The Lancet report remains the only epidemiological survey of excess deaths in Iraq from all causes - violence, heart attacks, strokes, infectious diseases, even car accidents. But the official campaign to discourage the media and the public from taking the Lancet report seriously was disturbingly effective. Even opponents of the war now cite much lower figures for civilian deaths and innocently attribute the bulk of them to acts of resistance.
The figures most often cited for civilian deaths in Iraq are those collected by Iraqbodycount, but its figures are not intended as an estimate of total deaths. Its methodology is to count only violent deaths that are reported by at least two approved international media outlets in order to generate a minimum number that is more or less indisputable. Its authors know that thousands of deaths go unreported in their count, especially in the resistance-held areas that are the targets of U.S. attacks, but they say they cannot prevent politicians and the media misrepresenting their figures as an actual estimate of deaths.
Other journalists cite the “Iraq Living Conditions” survey, which was conducted by the Iraqi planning ministry under the Coalition Provisional Authority in April and May 2004 and published in May 2005. It reported about 24,000 “war deaths”. This figure was derived from a single question posed to families in the course of a 1-1/2 hour interview on living conditions by government officials, and the Norwegian designer of the survey has agreed that it underestimated deaths.
Two actual counts of violent war deaths by independent Iraqi groups, the People’s Kifah and Iraqiyun, counted at least 37,000 deaths by October 2003, and 128,000 by July 2005 respectively. Actual counts of civilian deaths in a war zone are bound to be underestimates, which is one reason that epidemiologists rely on statistical samples in these environments.
Media watchdog groups have recognized that journalists are failing in their duty to accurately report the reality of the war. Project Censored has named the civilian death toll in Iraq the second most under-reported story of 2005, and Medialens has initiated a dialogue between Roberts and several people who made negative comments about his study in the press, leading some of them to retract those statements.
Beyond the phony controversy regarding the methodology of the Lancet report, there is one genuine issue that does cast doubt on its estimate of about 100,000 excess deaths by September 2004. This is the decision to exclude the cluster in Fallujah from its computations due to the much higher number of deaths that were reported there (even though the survey was completed before the widely reported assault on the city in November 2004). Roberts wrote in a letter to the Independent, “Please understand how extremely conservative we were: we did a survey estimating that ~285,000 people have died due to the first 18 months of invasion and occupation and we reported it as at least ~100,000”.
The dilemma he faced was this: in the 33 clusters surveyed, 18 reported no violent deaths, 14 other clusters reported a total of 21 violent deaths, and the Fallujah cluster alone reported 52 violent deaths. This last number is conservative in itself, because, as the report stated, “23 households of 52 visited were either temporarily or permanently abandoned. Neighbors interviewed described widespread death in most of the abandoned homes but could not give adequate details for inclusion in the survey”.
Leaving aside this last factor, there were three possible interpretations of the results from Fallujah. The first, and indeed the one Roberts adopted, was that the team had randomly stumbled on a cluster of homes where the death toll was so high as to be totally unrepresentative and therefore not relevant to the survey. Therefore, in the absence of a representative sample, the number of deaths in Anbar province had to be estimated based on the pattern in the rest of the country, in spite of evidence of much higher casualties. This interpretation generated the published estimate of 98,000 excess deaths.
The second possibility was that this pattern among the 33 clusters, with most of the casualties falling in one cluster and many clusters reporting zero deaths, was in fact an accurate representation of the distribution of civilian casualties in Iraq under “precision” aerial attack. This interpretation leads to an estimate of 285,000 excess deaths, with a higher proportion directly attributable to coalition air strikes.
The third possibility is that the Fallujah cluster was atypical, but not sufficiently abnormal to warrant total exclusion from the study, so that the true number of excess deaths was somewhere between 100,000 and 285,000. Without further research, there is no way to determine which of these three interpretations is correct, but the third one encompasses a range that includes the mid-points of other two, effectively making it the best estimate we’ve got. Based on this, we can also say that coalition forces may have killed as few as 35,000 or as many as 200,000 civilians in the first eighteen months of the war.
No new breakdown of the proportion of civilians killed by coalition forces has been published since the Health Ministry report last January, but the air war has definitely intensified during the last few months of 2005. Coalition air forces have acknowledged conducting about 270 air strikes in November and December, compared with 200 altogether in the eight months between January and August.
Independent journalists have described the continuing U.S. assault on Ramadi as “Fallujah in slow motion”, destroying the city block by block. Smaller towns in Anbar and Salahuddin provinces have been targets of air raids for the past several months. Seymour Hersh has covered the under-reported air war in the New Yorker and has written that the U.S. is planning to embed U.S. Special Forces with Iraqi auxiliary forces to call in air strikes after U.S. ground forces withdraw, opening the way for heavier bombing with even less media scrutiny (if that is possible).
Thanks to Roberts and Burnham, their international team and the editorial board of the Lancet, we have a more realistic and very different picture of the violence taking place in Iraq than that presented in the media. By now, allowing for a further eighteen months of the air war and other deaths since the completion of the survey, we have to estimate that somewhere between 200,000 and 700,000 people have died as a direct result of the war. Coalition forces have killed anywhere from 70,000 to 500,000 of them, including 30,000 to 275,000 children below the age of fifteen.
Les Roberts has cautioned me to remember that all the excess deaths are the result of the war, not just those killed by coalition forces. Whether someone is killed by a bomb, a heart attack during an air strike, or a car accident amid the chaos, those who initiated the war and have subsequently chosen to “stay the course” bear the overall responsibility.
It is deeply troubling that the number of human lives lost can only be described by such wide ranges, but they at least establish that the scale of this tragedy is greater than we have been told and underline the urgent need for a more appropriate international response. This response should include the withdrawal of foreign forces from Iraq; a no-fly zone over Iraq for American and British military aircraft; and support for dialogue between representative political groups in Iraq free from foreign coercion. The political leaders of the United States and the United Kingdom must be made to understand what most of their citizens have already worked out for themselves, that unleashing this terrible war has not earned them any legitimate role in the future of Iraq.
The official effort to suppress epidemiological research on civilian deaths in Iraq is a tacit admission that political leaders cannot find plausible justifications for the effects of modern war on civilian populations. Political justifications for war based on claims of some net benefit to the inhabitants of the country being attacked disintegrate when measured against the actual results of modern warfare. Denial, censorship and propaganda therefore permeate political strategies to unleash and then persist in such violence.
The mystification of “precision” weapons has been an effective tool to suggest that civilian casualties are being avoided or minimized. It is true that modern weapons are more accurate as well as more destructive, but the paradoxical effect has been that military planners now target “smart” bombs on inhabited, even urban, areas where they would be politically constrained from dropping “dumb” ones. But 15-25% of U.S. “precision” weapons used in Iraq miss their targets by more than 40 feet, and the Paveway II Mark 82 500 lb. bomb, the smallest bomb being dropped by U.S. warplanes in Iraq, is in any case designed to cause 50% casualties to a radius of 150 feet (about 1-1/2 football fields). As the editor of Jane’s Air Launched Weapons, Rob Hewson, has pointed out, “You can’t drop bombs and not kill people. There’s a real dichotomy in all this.”
The notion of a “threat” is another perennial element of war propaganda. In current political discourse in the United States, this word has become completely divorced from its literal meaning. In the absence of any actual military threat against the people or territory of the United States, American politicians and media now use the word “threat” to describe anything that poses a serious problem for U.S. strategic or commercial interests. Thus any actual threat of aggression by the United States anywhere in the world is politically justified as self-defense against a so-called “threat to U.S. interests”.
Denial, propaganda and claims of self-defense against the suspected plans of foreign governments as justification for killing hundreds of thousands of innocent civilians are horribly familiar to Benjamin Ferencz. He was a Chief Prosecutor at the U.S. War Crimes Tribunal at Nuremberg in 1946-7. As the sixtieth anniversary of the Nuremberg trials approaches, he has been kind enough to share some reflections with the U.N. Chronicle:
“General Dr. Otto Ohlendorf patiently explained why his unit had killed about 90,000 Jews. Killing all Jews and Gypsies was necessary, said Ohlendorf, as a matter of self-defense. According to Ohlendorf, it was known that the Soviets planned total war against Germany. A German preemptive strike was better than waiting to be attacked. It was also known, said Ohlendorf, that Jews supported the Bolsheviks - therefore all Jews had to be eliminated. But why did he, the father of five children, kill the little babes -- thousands of them? The bland reply was that if the children learned that their parents had been eliminated, they would grow up to be enemies of Germany. Long-range security was the goal. He lacked facts sufficient to challenge Hitler's conclusions. It was all very logical.”
The tribunal found Ohlendorf guilty of mass murder. Ferencz did not seek the death penalty, but the judges imposed it anyway. Ohlendorf was hanged on June 8th 1951.
- Kolko, Gabriel. 1994. Century of War. New York: The New Press.
- Waldman, Ronald. 2005. “Public Health in War – Pursuing the Impossible.” Harvard International Review: Vol.27, Issue 1
- Roberts, Les et al. 2004. “Mortality before and after the 2003 invasion of Iraq: cluster sample survey.” The Lancet: Vol. 364, 1857
- Edwards, David and David Cromwell. 2005. “Burying the Lancet Report – Parts 1 & 2.” www.medialens.org: September 5th 2005
- Ferencz, Benjamin B. 2005. “The Holocaust and the Nuremberg Trials.” U.N. Chronicle (December 2005)